Induced Pacemaker and Purkinje Cells from Adult Stem Cells

ABSTRACT

Adult stem cells are reprogrammed to form pacemaker cells and Purkinje cells through the sequential activation of SHOX2&gt;TBX5&gt;HCN2. These Purkinje cells spontaneously surround and connect with the larger pacemaker cells, thus forming an induced sinoatrial body that produces funny current and can make cardiovascular tissues beat in a manner similar to a natural sinoatrial node.

PRIOR RELATED APPLICATIONS

Not applicable.

FIELD OF THE DISCLOSURE

This invention relates to methods for the generation of non contractile,electrically active induced cardiomyocyte cells for use in treatment ofarrhythmias, as well as the induced creation and formation of cells forenhanced electrical activity of the heart such as sinus or sinoatrialnode cells and Purkinje cells of the heart thereby produced and used forsame.

BACKGROUND OF THE DISCLOSURE

The heart (FIG. 1A) is the muscular organ that pumps blood through theblood vessels of the circulatory system. In a healthy mammalian heart,composed of right and left atrium and right and left ventricles, bloodflows only one way through the heart because the heart valves preventbackflow. The heart is enclosed in a protective sac, the pericardium,which also contains a small amount of fluid. The wall of the heart ismade up of three layers: epicardium, myocardium, and endocardium.

The sinoatrial node (often abbreviated SA node or SAN; also commonlycalled the sinus node and less commonly the sinuatrial node) is thepacemaker of the heart and is responsible for the initiation of theheartbeat. It is located at the junction of the vena cava superior andthe atrium, and measures about 5 mm by 2 cm. It spontaneously generatesan electrical impulse, which after conducting throughout the heart,causes the heart to contract. Although the electrical impulses aregenerated spontaneously, the rate of the impulses (and therefore theheart rate) is modified by the nerves innervating the sinoatrial node,located in the right atrium (upper chamber) of the heart.

The atrioventricular (AV) node is a part of the electrical conductionsystem of the heart that coordinates the contractions of the heartchambers. It electrically connects atrial and ventricular chambers (FIG.1B). The AV node is an area of specialized tissue between the atria andthe ventricles of the heart, specifically in the posteoinferior regionof the interatrial septum near the opening of the coronary sinus, whichconducts the normal electrical impulse from the atria to the ventricles.The AV node is quite compact (˜1×3×5 mm). It is located at the center ofKoch's triangle—a triangle enclosed by the septal leaflet of thetricuspid valve, the coronary sinus, and the membraneous part of theinteratrial septum.

The distal portion of the AV node is known as the Bundle of His. TheBundle of His splits into two branches in the interventricular septum,the left bundle branch and the right bundle branch. The left bundlebranch activates the left ventricle, while the right bundle branchactivates the right ventricle. The two bundle branches taper out toproduce numerous Purkinje fibers, which stimulate individual groups ofmyocardial cells to contract.

Funny current (or funny channel, or If or IKf, or pacemaker current)refers to a specific current in the heart. First described in the late1970s in Purkinje fibers and sinoatrial myocytes, the cardiac pacemaker“funny” current has been extensively characterized and its role incardiac pacemaking has been investigated.

The funny current is highly expressed in spontaneously active cardiacregions, such as the sinoatrial node, the atrioventricular node and thePurkinje fibers of conduction tissue. The funny current is a mixedsodium-potassium current that activates upon hyperpolarization atvoltages in the diastolic range (normally from −60/−70 mV to −40 mV).When at the end of a sinoatrial action potential, the membranerepolarizes below the If threshold (about −40/−50 mV), the funny currentis activated and supplies inward current, which is responsible forstarting the diastolic depolarization phase (DD). With this mechanism,the funny current controls the rate of spontaneous activity ofsinoatrial myocytes and thus the cardiac rate.

The molecular determinants of the pacemaker current belong to theHyperpolarization-activated Cyclic Nucleotide-gated channels family(HCN) of which 4 isoforms (HCN1-4) are known to date. Based on theirsequence, HCN channels are classified as members of the superfamily ofvoltage-gated K+(Kv) and cyclic nucleotide-gated (CNG) ion channels.

In simple terms, the electrical signals that control the heartbeat canbe described as follows. The electrical impulse starts in the SA node.The electrical activity spreads through the walls of the atria andcauses them to contract. This forces blood into the ventricles. The AVnode acts like a gate that slows the electrical signal before it entersthe ventricles. This delay gives the atria time to contract before theventricles do. After this delay, the stimulus diverges and is conductedthrough the left and right bundle of His to the respective Purkinjefibers for each side of the heart, as well as to the endocardium at theapex of the heart, then finally to the ventricular epicardium. TheHis-Purkinje Network of fibers sends the impulse to the muscular wallsof the ventricles and causes them to contract. This forces blood out ofthe heart to the lungs and body. The SA node fires another impulse andthe cycle begins again.

Many things can go wrong with the heart resulting in irregular beating.Sick sinus syndrome—also known as sinus node disease or sinus nodedysfunction—is the name for a group of heart rhythm problems(arrhythmias) in which the sinus node—the heart's naturalpacemaker—doesn't work properly.

An artificial pacemaker is a medical device that uses electricalimpulses, delivered by electrodes depolarizing the heart muscles, toregulate the beating of the heart. The primary purpose of the artificialpacemaker is to maintain an adequate heart rate, either because theheart's natural pacemaker is not fast enough, or because there is ablock in the heart's electrical conduction system. Modern pacemakers areexternally programmable and allow a cardiologist to select the optimumpacing modes for individual patients. Some combine a pacemaker anddefibrillator in a single implantable device. Others have multipleelectrodes stimulating differing positions within the heart to improvesynchronization of the higher (atria) and the lower chambers(ventricles) of the heart.

Although artificial pacemakers have saved many lives, they are not aperfect solution. In particular, they are not hormone responsive, aresubject to mechanical and/or electrical failure, need batteryreplacement and can be disrupted in strong magnetic fields or intherapeutic radiation settings. Further, infection is always a hazard,as is pacemaker-mediated tachycardia, suboptimal atrioventricular (AV)synchrony, and several other types of pacemaker induced dysrhythmias.Therefore, there are ongoing efforts to develop a more naturalpacemaker.

Biological pacemakers, generally intended as cell substrates able toinduce spontaneous activity in silent tissue, represent a potential toolto overcome the limitations of electronic pacemakers. Efforts to developnatural pacemakers for use in place of artificial pacemakers havegenerally taken one of two approaches.

One approach is to convert beating myocardium into pacemaker cells insitu via genetic manipulations (i.e., direct reprogramming). In thisregard, the early key transcription factor TBX3 provided promisingresults, but led to cells with incomplete pacemaker characteristics.

Another approach is to use embryonic or induced pluripotent stem cells(so called IPS cells) that have been programmed to form pacemaker cells,and then replace or supplement AV cells with these newly programmedAV-like cells.

In a study, Jung et al. attempted to generate pacemaker cells byup-regulation of TBX3 in induced pluripotent stem cells (iPSCs). Hashemet al. (2013) indicated that SHOX2 regulates the pacemaker gene programin embryoid bodies. Bakker et al. (2012) attempted to reprogramterminally differentiated cardiomyocytes towards pacemaker cells byupregulation of TBX3. In another study Kapoor et al. (2013) attempted togenerate pacemaker cells by overexpression of TBX18 in adultcardiomyocytes. Hu et al. (2014) tried to convert cardiomyocytes intopacemaker cells by upregulation of Tbx18.

Despite several attempts in the past to generate cardiac pacemakercells, there are up to now no correctly functional biological pacemakercells available for clinical application derived from undifferentiatedadult autologous stem cells. It only has been shown before that cellslike embryonic cells or IPS cells could be induced by manipulation ofcertain genes to obtain some features that are present in pacemaker orin other cells of the cardiac conduction system. The expression of asingle transcription factor alone was not able to switch on the completerespective regulatory differentiation pathway towards pacemaker orPurkinje cells. Attempts to generate pacemaker cells in the past failedto mimic the appropriate physiological functionality and morphologicalproperties of natural cardiac pacemaker cells.

The work described herein, takes this research to a new and higherstate: The induction of differentiation of adult, unmodified, freshuncultured cells (herein also called regenerative cells) from thepatient's own tissue into non-contractile cardiomyocyte cells withmorphological and functional structure and features of naturalpacemakers and Purkinje cells has not been achieved before.

SUMMARY OF DISCLOSURE

Induced pacemaker cells, Purkinje cells and the sinoatrial bodiesproduced by their association are described herein, as well as method ofmaking and using same.

Using both lentiviral and mRNA based transfection approaches, adiposederived stem cells (ADSCs) have been reprogrammed towards cardiacpacemaker cells by the respective subsequent application of acombination of transcription factors including SHOX2, TBX3, TBX5, TBX18and HCN2.

SHOX2 is a negative regulator of NKX 2.5 in the SA node, which inhibitsthe contractile cardiomyocytes differentiation pathway, but specificallydirects the primitive respectively progenitor cells toward thenon-contractile cardiomyocyte pacemaker cell lineage by up-regulation ofthe pacemaker differentiation pathway. TBX3, TBX5 and TBX18 are the maintranscription factors regulating the differentiation of primitivemesodermal derived stem cells towards the pacemaker cell lineage and theformation of SAN.

Mature pacemaker cells at the late stage of tissue development differfrom common cardiomyocytes for the presence of spontaneousdepolarization processes, which are caused by an unstable phase 4potential that progressively reduces the membrane potential during thediastolic phase of the cardiac cycle. When the reduction reaches acritical threshold value, the sodium channels open and the actionpotential induces. The spontaneous diastolic depolarization of pacemakercells is due to the hyperpolarization-activated cyclic nucleotide-gated(HCN) channel genes, which code for specific proteins, providing thepresence of an inward current named If or funny current. Expression ofHCN2 is believed to be important for appropriate physiologicalfunctionality of pacemaker cells, but its possible that other HCN genescan replace or supplement HCN2.

The invention is described in more detail below.

Pacemaker Reprogramming Genes

SHOX2 (UniProt 060902), aka SHORT STATURE HOMEOBOX 2 or SHOT, wasidentified as gene related to the human short stature homeobox gene(SHOX; 312865) and the mouse og12 gene. The original discoverers showedthat SHOX2 shows a much higher degree of homology to og12 than doesSHOX. Two different isoforms were isolated, called SHOTa and SHOTbtherein, which have identical homeodomains and share a C-terminal14-amino acid residue motif characteristic for craniofacially expressedhomeodomain proteins. The differences between SHOTa and SHOTb werewithin the N-termini and an alternatively spliced exon in the C termini.In situ hybridization of og12 on sections from staged mouse embryosdetected highly restricted transcripts in the developmental sinusvenosus (aorta), female genitalia, diencephalon, mes- andmyelencephalon, nasal capsula, palate, eyelid, and limbs. Isoform 1 is330 amino acids and contains a homeobox DNA-binding domain.

TBX5 (UniProt Q99593), aka T-BOX-5, spans 9 exons and more than 47 kband mutations in this protein are responsible for Holt-Oram syndrome, adevelopmental disorder affecting the heart and limbs. Researchers foundthat P19CL6 cell lines overexpressing wildtype TBX5 started to beatearlier and expressed cardiac-specific genes more abundantly than didparental P19CL6 cells, whereas cell lines expressing the G80R mutation(601620.0004), which causes substantial cardiac defects with minorskeletal abnormalities in HOS, did not differentiate into beatingcardiomyocytes. Contrarily, the R237Q mutation (601620.0003), whichcauses upper limb malformations without cardiac abnormalities, activatedthe Nppa promoter to an extent similar to that of wildtype TBX5. Isoform1 is 558 amino acids.

In place of or in addition to TBX5, TBX3 (UniProt 015119) can be used inthe methods described herein. TBX3, aka T-BOX-3, identified along withTBX5 in studying linkage to Holt-Oram syndrome. There are alternativelytranscribed TBX3 transcripts, including 1 that interrupts the T-box. Thecomplete open reading frame of the TBX3 gene encodes a predicted723-amino acid protein. Comparison of other T-box genes to TBX3indicated regions of substantial homology outside the DNA-bindingdomain.

In addition to being involved in limb pattern formation, TBX3 isinvolved in pacemaker development. Using genetic lineage analysis,knockout studies, and explant assays, it was found that TBX18 (OMIM604613) was required to establish the large head structure of the mousesinoatrial node from mesenchymal precursors. Subsequently, TBX3 inducedexpression of pacemaker genes for pacemaker function. It has also beenused to improve the quality of induced pluripotent stem (iPS) cells.

TBX18 (UniProt 095935) can also be used in the methods described herein.TBX18 or T-BOX-18 acts as transcriptional repressor involved indevelopmental processes of a variety of tissues and organs, includingthe heart and coronary vessels, the ureter and the vertebral column. Itis required for embryonic development of the sino atrial node (SAN) headarea. As typical in this family, there are several exons (8), at least 4transcripts, and the full length protein is 607 aa.

HCN2 (UniProt Q9UL51), aka HYPERPOLARIZATION-ACTIVATED CYCLICNUCLEOTIDE-GATED POTASSIUM CHANNEL 2 and BRAIN CYCLIC-NUCLEOTIDE GATED2; BCNG2, is believed to be one of the pacemaker ion channels. The HCN2gene contains 8 exons spanning about 27 kb, and like all channels it isquite large at 889 amino acids, having at least 6 transmembrane domains.This hyperpolarization-activated ion channel exhibits weak selectivityfor potassium over sodium ions, and contributes to the native (funny)pacemaker currents in heart (If).

Method Overview

Generally speaking, we use adult uncultured and initially unmodifiedadipose tissue derived regenerative cells that include very earlypluripotent stem cells and progenitor cells. The use of autologous cellsfrom the same patient that requires repair of an arrhythmia of his orher heart, both bradycardic or tachycardic, is preferred.

These cells are transfected with sequential expression vectors encodingSHOX2, TBX5 and HCN2, or SHOX2, TBX3, TBX5, TBX18 and HCN2 such thateach of the genes is transcribed in a sequential and organized mode,leading to production of functional proteins.

The use of adipose tissue derived stem cells is exemplary only and anysuitable regenerative cell preparation can be used. Regenerative cellspreparations for example include cells from bone narrow, umbilical cordtissue, umbilical cord blood, placenta, blood or any other tissue of thebody such as roots of hair or omental fat containing blood vessels andthereby containing the early stem cells that are able to be induced togenerate pacemaker cells with the method described in this application.This list of possible cells is only exemplary and not exhaustive.

In our experience, the proteins should be sequentially introduced intothe cell in a particular sequence order and amount (FIG. 2). Attemptingto transfect all genes at once killed a majority of cells. However, withbetter introduction systems, it may be possible that the cells will notbe as shocked and may survive. Order of activation, however, is expectedto continue to be important, as is the level of expression.

The vectors used herein were lentiviral vectors, however, this isexemplary only and any expression vector can be used. Alternatively, RNAcould be used or even intact functional proteins.

DNA, RNA and protein can be introduced into the cells in a variety ofways, including e.g., microinjection, electroporation, andlipid-mediated transfection. RNA can also be deliver to cells usinge.g., tat fusion using e.g., the HIV-1-tat protein. Tat has successfullybeen used for protein delivery. For example, atetramethylrhodamine-labeled dimer of the cell-penetrating peptide TAT,dfTAT, penetrates live cells by escaping from endosomes with highefficiency. Other cell-penetrating peptides (CPPs) are known, and indeedintact proteins can be delivered using CPPs as fusion proteins, as wellas by non-covalent CPP/protein complexes.

At the current time retroviruses are preferred for gene therapies(retroviral and lentiviral) and have now been used in more than 350gene-therapy studies. Retroviral vectors are particularly suited forgene-correction of cells due to long-term and stable expression of thetransferred transgene(s), and also because little effort is required fortheir cloning and production. However, it is anticipated that nextgeneration vectors will continue to be developed that can be equallyused for the purpose of induction of pacemaker cells.

Furthermore, with the advent of genome engineering techniques (such asCRISP/CAS, and the like), it may also be possible in the future toselectively activate the needed proteins via genome engineering, ratherthan by cell delivery of DNA, RNA, or protein. Selective epigeneticchanges (e.g., changing methylation patterns) may also be possible inthe future, but are currently impractical.

While a number of different adult pluripotent stems cell sources couldbe used herein, one important aspect of the invention lies in generatingcells for treating sick sinus syndrome and other arrhythmias in humans.The preferred source of stem cells are autologous cells, such as e.g.,adipose tissue derived regenerative cells from the same patient thatneeds repair of arrhythmias. Adipose tissue is preferred as containing ahigh number of these early pluripotent cells that are able to undergowith the appropriate sequential induction to form non-contractile, butelectrically special cells such as pacemaker and Purkinje cells, thatassociate to form a sinuatrial body. Adipose tissue is readily availablefrom the patient without the discomfort associated with tapping bonemarrow sources or using allogenic cells obviating any rejection issues.In the future, when more and more patients have stored e.g., umbilicalcord blood and/or umbilical or placenta derived stems cells and thelike, other types of stem cells may be preferred in a matched allogenictransplant procedure, but at the current time, for few patientscurrently these resources exist yet.

No one has to this point been able to use uncultured or cultured adult,i.e. non embryonic and non-iPS stem cells, for the creation of inducedsinoatrial cells that show the characteristics of pacemaker cells bothon the morphological level and the functional level. The use of thesecells represents a tremendous advantage over embryonic stem cellsbecause they can be autologous, eliminating rejection problems, and arereadily available, unlike embryonic stem cells. Furthermore, inducedpluripotent stem (iPS) cells may not be safe—several reports recentlyindicated that such cells are close to cancer cells.

Allogenic cells may also be suitable, although immunomodulatory drugsare typically required if the HLA pattern does not match. However, suchcells are in use today, and may be more amenable to use in the future asmore and more banks collect and store cord blood, cord tissue stemcells, etc. and the stem cells generated thereby, particularly wherelibraries of hundreds and thousands of different HLA patterns can becollected and cryopreserved, so that the probability of a matchedallogeneic transplant increases. Alternatively, a library of inducedpacemaker/Purkinje cells can be generated in advance, so at the time ofneed, these cells will be readily available for transplantation.

Furthermore, we have described the invention using human wild typegenes, but other sources may be used as appropriate for the species.Codon optimization can also be performed to optimize expression.

The invention includes and one or more of the following embodiments, inany combination(s) thereof:

A method of inducing stem cells, especially adult stem cells todifferentiate into an induced non-contractile cardiomyocyte cell types,such as pacemaker, Purkinje and sinoatrial body cells, said methodcomprising inducing the sequential expression of SHOX2 > TBX5 > HCN2 ina population of stem cells in order to reprogram said stem cells, andgrowing said reprogrammed cells until cardiac pacemaker cells andPurkinje cells form and associate into an induced sinoatrial body. Amethod of repair of the natural pacemaker in the heart, said methodcomprising obtaining stems cells from a patient with a malfunctioningpacemaker, inducing sequential expression of SHOX2 > TBX5 > HCN2 in saidstem cells to form reprogrammed cells, and growing said reprogrammedcells until cardiac pacemaker cells and Purkinje cells form andassociate into an induced sinoatrial body, and introducing said inducedsinoatrial body into a heart of said patient. A method as hereindescribed, wherein said stem cells are autologous stem cells from thepatient's own body. A method as herein described, wherein said stemcells are autologous adipose derived stem cells. Cord blood, cord tissueand bone derived stem cells could also be used. A method as hereindescribed, comprising inducing the sequential expression of SHOX2 >TBX5 > TBX3 > TBX18 > HCN2, or the sequential expression of SHOX2 >TBX5 > [TBX3 and/or TBX18 in either order] > HCN2, or the sequentialexpression of SHOX2 > [TBX5 or TBX3 or TBX18] > HCN2. A method as hereindescribed, wherein said inducing step uses one or more expressionvectors, preferably a lentiviral vector, encoding the needed proteins. Amethod as herein described, wherein said inducing step uses thesequential application of mRNA as the recited proteins. An inducedsinoatrial body made by any method herein. A composition comprising apopulation of reprogrammed cells formed from stem cells transformed withexpression constructs allowing the sequential expression of SHOX2 >TBX5 > HCN2, thus forming said reprogrammed cells. Preferably, thepopulation is containing in a pharmaceutically acceptable liquidexcipients and/or a cell support medium that functions to safely supportsaid cells until use, or even a cell growth medium, that allows theirgrowth (growth meaning cell division) until use. A compositioncomprising a population of reprogrammed cells formed from stem cellstransformed with expression constructs allowing the sequentialexpression of SHOX2 > (TBX5 and TBX3 and TBX18) > HCN, thus forming saidreprogrammed cells A composition comprising a population of reprogrammedcells formed from stem cells transformed with expression constructsallowing the sequential expression of SHOX2 > TBX5 > TBX3 > TBX18 >HCN2, thus forming said reprogrammed cells An expression vectorcomprising inducible genes encoding proteins SHOX2, TBX5 and HCN2, suchthat each gene can be sequentially induced. An expression vectorcomprising a first inducible promoter operably linked to a gene encodingSHOX2, a second inducible promoter operably linked to a gene encodingTBX5, and a third inducible promoter operably linked to a gene encodingHCN2, such that each gene can be sequentially induced by first, secondand third inducers. Likewise, the other genes described herein can besimilarly employed. A method as herein described, further includingseparating said pacemaker cells and said Purkinje cells by size sorting.The separated cells can also be used for treatments, for example,Purkinje cells can be used to treat tachycardiac arrhythmia andpacemaker cells can be used to treat sick sinus syndrome. A method asherein described, wherein said adult stem cells are obtained from apatient with a tachycardiac arrhythmia, and wherein said separatedPurkinje cells are administered to said patient in an amount sufficientto treat said tachycardiac arrhythmia. A method as herein described,wherein said adult stem cells are obtained from a patient with sicksinus syndrome, and wherein said separated pacemaker cells areadministered to said patient in an amount sufficient to treat said sicksinus syndrome. Any treatment method herein wherein a defectivesinoatrial body is ablated before said administration step. These can beablated with heat, lasers, cryogenically, and the like. In such asmethod, the heart will only be guided by the induced sinoatrial body orthe induced cells, and no conflicting electrical signals would bepresent.

As used herein, “an induced sinoatrial body” consists of reprogrammedstem cells that have been induced to form pacemaker and Purkinje cellsthat have then associated to form functional interconnections andproduce an induced sinoatrial body that generates funny current and caninduce heart beating. Functional interconnection andelectrophysiological properties of pacemaker and Purkinje cells areassociated with the expression of specific cell membrane junctions andion channels; specifically in terms of cardiac conduction cells,including CX30.2 and HCN4 (FIG. 10, 11).

As used herein, a pacemaker cell is a large primarily round (>50 μm)cell with several spider-like protrusions that has the ability tospontaneously depolarize (FIG. 7, 8).

As used herein, a “Purkinje cell” is a small (<20 μm across the diameterof the main cell body), cell that forms specific chains with each otherand spontaneously orient itself in chains and channels, will surroundand form interconnections with a pacemaker cell (FIG. 7, 8, 9).

As used herein, “inducing” the expression of certain genes in stem cellsdoes not imply any particular methodology, and is not limited to the useof inducible promoters. Instead, any means of turning on gene expressioncan be used, including the use of expression vectors, naked DNA or RNAor protein, induced epigenetic changes, and the like. It does notinclude those natural cells that already demonstrate expression of therecited gene/proteins, but only stems cells that have been re-programmedto do so by the hand of man.

As used herein, “stems cells” or “regenerative cells,” includesmultipotent and pluripotent stems cells, as well as other types of cellsthat can be successfully reprogrammed to differentiate into the celltypes described herein. These are cells that are not yet differentiated,or have been dedifferentiated, and thus have the potential to eitherform all cell types, or a multiplicity of cell types.

“Adult stem cells” are typically multipotent stem cells derived from anon-infant person, and does not imply any particular age of the donor.Also known as somatic stem cells, they can be found in children, as wellas adults.

As used herein, “autologous” means cells derived from the patient or agenetically identical patient. “Allogenic” refers to cells derived fromthe same species, but having a different genotype.

The use of the word “a” or “an” when used in conjunction with the term“comprising” in the claims or the specification means one or more thanone, unless the context dictates otherwise.

The term “about” means the stated value plus or minus the margin oferror of measurement or plus or minus 10% if no method of measurement isindicated.

The use of the term “or” in the claims is used to mean “and/or” unlessexplicitly indicated to refer to alternatives only or if thealternatives are mutually exclusive.

The terms “comprise”, “have”, “include” and “contain” (and theirvariants) are open-ended linking verbs and allow the addition of otherelements when used in a claim.

The phrase “consisting of” is closed, and excludes all additionalelements.

The phrase “consisting essentially of” excludes additional materialelements, but allows the inclusions of non-material elements that do notsubstantially change the nature of the invention. Elements of this typewould include e.g., buffers, chelators, nutrients, instructions for use,and the like.

The following abbreviations are used herein:

ABBREVIATION TERM αMEM MEM with Earles balanced Salts ADST Adiposederived stem cells cDNA Copy DNA DNA Deoxyribonucleic acid EKGElectrocardiogram, also ECG FBS Fetal bovine serum MEM Minimum-essentialmedium PBS Phosphate buffered saline PCR Polymerase chain reaction qPCRQuantitative PCR RNA Ribonucleic acid SAN sinoatrial node

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A. ANATOMY OF THE HEART: Diagram of the anatomy of a heart incross section, with EKG trace (upper right).

FIG. 1B. ELECTROPHYSIOLOGY OF THE HEART: Electrical system of the heartand EKG trace in detail.

FIG. 2. GENE ACTIVATION SEQUENCE: Schematic algorithm representing thecritical genes involving in different stages of cardiac pacemaker celllineage development.

FIG. 3. EXPERIMENTAL OVERVIEW: Schematic diagram, representative ofsequence of experimental procedures for generation of cardiac pacemakercells.

FIG. 4. VECTOR MAP: PNL-TREPiTT-EGFP deltaU3-IRES2-EGFP plasmid used asan expression vector for TBX3, TBX5, TBX18, HCN2, SHOX2 constructs.

FIG. 5. ADSC BEFORE AND AFTER TRANSFECTION: Changes in the morphology ofADSCs after transfection with cardiac pacemaker inducing factors SHOX2,TBX5 and HCN2 from the typical fibroblastic like morphology of ADSCs (A)to the colonies of small network forming cells (B), see arrow, 7 daysafter initiation under a doxycycline dependent switch.

FIG. 6. CHANGING MORPHOLOGY: Changes in the morphology of ADSCs aftertransfection with cardiac pacemaker inducing factors SHOX2, TBX5 andHCN2 from the typical fibroblastic like morphology of ADSCs to thecolonies of small and large network forming cells within 1 week afterinitiation of doxycycline switch controlled induction.

FIG. 7. CELL TYPES AND ALIGNMENT: Observation of 2 different cell typesin culture plate of ADSCs transfected with SHOX2, TBX5 and HCN2.Right-arrow—Small cell population with spike shape projections. Smallcells start to form a special aligned growth pattern and make channellike structures. Left arrow—Larger cells with special spider shapemorphology.

FIG. 8. CLOSEUP OF LARGE CELLS: Appearance of typical spiderlikemorphology of large cells (>50 μm) within 14 days after initiation ofdoxycycline controlled induction of SHOX2, TBX5 and HCN2.

FIG. 9. NETWORKS: Large spider shape cells start to form networks witheach other and with small cells within 3 weeks after induction of SHOX2,TBX5 and HCN2.

FIG. 10. DAPI AND CX30.2 IN SMALL CELLS. Expression of CX30.2 (aspecific marker of pacemaker cell lineage) in small network formingcells. The blue DAPI stain lights up DNA, indicating the nucleus.

FIG. 11. DAPI and CX30.2 IN LARGE CELLS. Expression of CX30.2 in bothsmall and large spider shaped cells.

FIG. 12. DAPI AND HCN4 (a specific marker of pacemaker cell lineage) inboth small and large cells.

FIG. 13. RNA EXPRESSION LEVELS. mRNA expression levels of specificmarker genes of cardiac Purkinje cells in ADSCs transfected withdifferent combinations of pacemaker inducing factors, 2 weeks after theinitiation of induction.

FIG. 14. RNA EXPRESSION LEVELS CONT. mRNA expression levels of specificmarker genes of cardiac pacemaker cells in ADSCs transfected withdifferent combinations of pacemaker inducing factors, 2 weeks after theinitiation of SHOX2, TBX5 and HCN2 induction.

FIG. 15. SINGLE CELL VOLTAGE CLAMP EXPERIMENTS, FUNNY CURRENT CONTROLCELLS: Representative funny current (If) recorded from ADSCs (Control 2)cells. The If currents were elicited with voltage steps from −100 mV to−40 mV for 500 mS with 10 mV increment from a holding potential of −40mV.

FIG. 16. FUNNY CURRENT IN SMALL CELLS: representative funny current (If)recorded from small size fraction (<20 μm cell size) of ADSCstransfected with SHOX2, TBX5, and HCN2. The If currents were elicitedwith voltage steps from −100 mV to −40 mV for 500 mS with 10 mVincrement from a holding potential of −40 mV.

FIG. 17. FUNNY CURRENT IN LARGE CELLS. Representative funny current (If)recorded from large size fraction (>50 μm cell size) of SHOX2, TBX5,HCN2 transfected ADSCs. The If currents were elicited with voltage stepsfrom −100 mV to −40 mV for 500 mS with 10 mV increment from a holdingpotential of −40 mV.

DETAILED DESCRIPTION

The invention provides novel methods of making pacemaker cells andPurkinje cells or sinoatrial nodes (SANs); the pacemaker cells, Purkinjecells, and SANs made thereby; and methods of using same, e.g., toreplace or supplement damaged pacemakers and Purkinje fibers in theheart of patients, such as human patients. The cells can be surgicallydelivered directly or by catheter based injection to the place wherethey are required. For the repair of the sinus node for example, acatheter based injection of a few thousand cells into the damaged andreduced functioning sinus node is sufficient to effect repair.

For the repair of tachycardic arrhythmias, Purkinje cell are injectedinto the slow conducting zone, such as the border zone of an infarction,in order to accelerate the speed of conduction in this arrhythmogenicsubstrate and thereby to close the re-entry pathway by accelerating thecirculating impulse in such a way that it meets refractory myocardiumand the re-entry is interrupted.

Preferably, the cells are made from autologous cells, using anyavailable stem cell source from the patient, such as bone marrow derivedstem cells or adipose derived or blood, skin and umbilical cord tissuederived stem cells.

Lentiviral-Based Reprogramming

To induce ADSCs to differentiate into cardiac pacemaker cells, they aresequentially transfected with different combinations of cardiacpacemaker inducing factors including SHOX2, TBX5, TBX3, TBX18 and HCN2by applying a lentiviral vector system. The lentiviral vector is underthe control of a switch, for example a doxycycline switch.

The expression of cardiac pacemaker inducing factors was achieved bylentiviral vectors, applied to the cells in the sequential way in24-hour intervals (FIG. 3). Cells were cultured in α-MEM supplanted with5% horse serum, 2 mM glutamine, 0.1 mM non-essential amino acids.Cultures were treated daily with 400 ng/ml doxycycline for 3 days, thensustained for 2 weeks in α-MEM with above mentioned supplements. Dailymicroscopic observation of cells was performed to study themorphological changes of cells after the transfection. RNA samples werecollected from different experimental groups at day 14 after theinitiation of Doxycycline induction.

TABLE 1 List of experimental groups by controlled expression of single,double and triple combinations of pacemaker inducing factors in ADSCsExperimental Groups' Name Description of Treatments T3 ADSCs transfectedwith TBX3 only T5 ADSCs transfected with TBX5 only T18 ADSCs transfectedwith TBX18 only HCN- 2 ADSCs transfected with HCN2 only SHOX2 ADSCstransfected with SHOX2 only SH ADSCs transfected with double combinationof SHOX2 and HCN2 SHT- 3 ADSCs transfected with triple combination ofSHOX2, TBX3 and HCN2 SHT- 5 ADSCs transfected with triple combination ofSHOX2, TBX5 and HCN2 SHT- 18 ADSCs transfected with triple combinationof SHOX2, TBX18 and HCN2

Human ADSCs (hADSCs) were obtained from INGENERON® (Houston, Tex.).Adipose tissue from donors aged 30-40 years old were obtained withinformed consent under a tissue acquisition protocol approved by theInstitutional Review Board. The ADSCs were prepared from lipoaspirateacquired from donors undergoing elective lipoplasty. The hASDCs wereisolated as described previously.

Briefly, fat tissue was minced and incubated for 30 min at 39° C. withMatrase (INGENERON®) at a concentration of 1 unit per gram of fat tissuein Ringer solution in the Transpose RT™ processing unit (INGENERON®).The processed tissue was subsequently filtered through a 100 μm filterand centrifuged at 450 g for 10 min. The supernatant containingadipocytes and debris were discarded, and the pelleted cells were washedtwice with Hanks' balanced salt solution (CELLGRO™) and finallysuspended in growth media. The process is described in detail byinstructions for use of InGeneron Transpose RT™ system (INGENERON®).Growth media contained alpha-modification of Eagle's medium (CELLGRO™),20% FBS (ATLANTA BIOLOGICALS™), 2 mM glutamine, 100 units/ml penicillinwith 100 μg/ml streptomycin (CELLGRO™)

Adherent cells were called hADSCs and grown in culture flasks at 37° C.in a humidified atmosphere containing 5% CO₂ followed by daily washes toremove red blood cells and non-attached cells. On reaching 80%confluence, cells were detached applying Trypsin solution 0.25% andseeded at the density of 3000 cells/cm² in fresh cell culture flasks.

To differentiate ADSCs into cardiac pacemaker cells, the ADSCs weretransfected with different combinations of cardiac pacemaker inducingfactors including SHOX2, TBX3, TBX5, TBX18 and HCN2 using a lentiviralvector system (Table 1). The lentiviral vector used herein includespacking vector psPAX2 and envelope vector pMDS2.G (ADDGENE™) (Islas,2012). In addition, a Doxycycline controlled transactivator (rtTA2) wasused as a transcriptional inductive switch of the system. PlasmidPNL-TREPiTT-EGFP delta U3-IRES2-EGFP (FIG. 4) was used as a backbonevector for every single gene. A commercial cell line—293FT—was used forviral packaging. The 293FT cell line is a fast-growing, highlytransfectable clonal isolate derived from human embryonal kidney cellstransformed with the SV40 large T antigen and is available from THERMOFISCHER SCIENTIFIC®.

Briefly viral particles were produced in 293 T cells transfected withpsPAX2, pMDs2.G vectors and plasmids containing every single gene ofinterest including SHOX2, TBX3 TBX5, TBX18, HCN2. Reprogramming of about80% confluent ADSCs into proliferative state were accomplished byinfection with different combinations of the viral particles containingSHOX2, TBX3, TBX5, TBX18, HCN2 vectors according to the predefinedexperimental groups (see Table 1). The 4 and 5 gene combinations alsopresent good preliminary results.

Transfected cells were cultivated in large tissue culture plates byα-MEM (INVITROGEN®) supplemented with 5% (vol/vol) horse serum, 0.1 mMnon-essential amino acids, 2 mM L-glutamate.

The stable integration and mRNA expression of each gene construct wereconfirmed 72 hours after the transfection using PCR.

To study any changes occurring in the cells after the transfection,delicate microscopic observation of cells were performed every day.Representative data are shown herein, that belonging to the tripletcombination of the sequential transfections of SHOX2>TBX5>HCN2.

Starting from week 2 after Doxycycline triggered treatment geneticallyprogrammed pacemaker cells from different experimental groups initiatedto convert their fibroblastic like morphology and formed new coloniescontaining a particular network forming cell type with several largespike shape projections. The sequential transfections of SHOX2>TBX5>HCN2are shown in FIG. 5, 6.

During the differentiation period in various experimental groups,gradually two different types of cells appeared, including a particularlarge spider shape cell type and small spindle shape cells with longspike like projections. FIG. 7, 8 shows the appearance of the two celltypes in the triple sequential transfections of SHOX2>TBX5>HCN2.Subsequently, both populations of spindle and spider shape cells beganto form highly interconnected networks with each other (FIG. 9). Inaddition small spike shape cells started to form particular, highlyaligned growth patterns (see linear groove forming in FIG. 7, likelycorresponding to Purkinje cell networks in the natural conduction systemof heart.

According to the results of previous studies on isolation of pacemakercells from fetal SAN, spider shape morphology has been defined as atypical morphology of pacemaker cells. Therefore, our orderedtransfection experiments showed that the triplet sequentialtransfections of SHOX2>TBX5>HCN2 made cells with a morphology very muchlike natural pacemaker cells.

Although not shown herein, the similar observations were made indifferent groups of ADSCs transfected with various combinations ofpacemaker inducing factors. However, more robust morphological changestoward the typical morphology of cardiac conduction cells were observedin ADSC groups transfected with TBX transcription factors (particularlyTBX5) in comparison with the groups transfected with individual ordouble combinations of SHOX2 and HCN2. The most robust morphologicalchanges were observed in ADSCs group transfected with triplecombinations of SHOX2, TBX5 and HCN2, and therefore these results areshown in part herein. Similar results were observed in expression ofmolecular markers of cardiac conductive system by qPCR assay (FIG. 13,14).

Results of earlier in vivo studies on identifying the main molecularregulators of cardiac conduction system development identified T-boxproteins as essential factors for cardiac conduction systemmorphogenesis as well as the up-regulation of genes encoding the ionchannel proteins that contribute to the electrophysiologicalfunctionality of cardiac conduction cells.

Hoogaars e al., 2007 indicated that TBX3 controls the sinoatrial nodegene program and imposes pacemaker function on the atria. Results ofother studies indicating TBX5 is a critical transcription factorregulating developmental networks required for maturation of andfunctionality of cardiac conduction cells.

Results of genome wide associate studies (GWAS) have identified numerousloci associated with the developmental processes of human cardiacconduction system including TBX5 and ion channels. Expression of ionchannels is critical for electrophysiological functionality of thesystem. Arnold et al., 2012 found that deletion of TBX5 results insevere malfunction in cardiac conduction system including loss of fastconduction, arrhythmias and sudden death.

In addition based on the results of genome wide associate studies (GWAS)a molecular link was identified between TBX5 and SCN5A (UNIPROT Q14524),aka NAV1.5, a key mediator of fast conduction system. Results of thisstudy identified a TBX5-responsive enhancer downstream of SCN5A, whichis sufficient for the lineage specification of ventricular conductionsystem (Arnolds, 2012).

The smaller cells correspond to Purkinje cells, as determined by spindlelike morphology and long cellular projections: Two weeks aftertransfection these small spindle like cells illustrated particularly ahighly aligned growth pattern, including formation of multicellularstrands and networks through the tight connection of individual cells toeach other. These cells illustrated moderate levels of funny currents insingle cell patch clump assay. According to the results of previous invivo studies on isolation and characterization of various cardiac celltypes, this particular strand and network forming growth pattern hasbeen defined as the typical characteristics of Purkinje cells. Similarmorphological properties were reported in a previous attempt for invitro production of cardiac nodal cells through the overexpression ofTBX3 in ESCs. In addition in agreement with our findings, results ofprevious studies on characterization of different types of cardiacconductive cells also revealed the lower levels of electrophysiologicalactivity in cardiac Purkinje cells in comparison with the pacemakercells.

The two cells types associate to form interconnected networks whereinone pacemaker cell is surrounded and connected to several Purkinje cellsto form a network. The Purkinje cells have the purpose to act asamplifier and conductors of the initial spontaneous depolarizationinduced by the pacemaker cells. The formation of these interconnectednetworks is closely correlated with the expression of specific membranejunctions and ion channels of cardiac conduction cells including CX30.2and HCN4, essential for the electrophysiological functionality of cells.HCN4, which is a member of hyperpolarization activated cyclicnucleotide-gated sodium channels, is required for If, the specificpacemaker current. CX30.2 is responsible for the cell-cell junctions andformation of networks between spontaneously depolarizing cardiomyocytecells.

RNA-Based Reprogramming

Another successful way to induce a programmed pacemaker non-contractilecardiomyocyte cell is using a mRNA-based transfection method. Thismethodology has not yet been fully completed on all different inducingfactors, but our current results suggest the method to be equally viableand effective.

Briefly, coding DNA sequence is amplified by PCR using specific primers.PCR products then are purified and the quality of the generated DNA isdetermined. Using the in vitro transcription (IVT) process, mRNA isgenerated from the DNA product. Subsequently, the product is purifiedand treated with phosphatase to remove 5′-triphosphates. After theadditional purification and quality control of generated mRNA,transfection experiments will be performed.

To obtain, the DNA template for the IVT, all TBX18, TBX3 and HCN2plasmids are amplified using PCR. Thereby, a poly T-tail of 120thymidines (T) is added to the insert by using a reverse primer with aT₁₂₀ extension. Thus, after IVT, the generated mRNAs obtain a polyA-tail with a defined length. PCR reactions of 100 μl will are performedusing e.g., HOTSTAR™ HIFIDELITY POLYMERASE KIT (QIAGEN®, Germany) andcontained 0.7 μM of each forward and reverse primer, 1× Q-solution, 1×HOTSTAR™ HIFIDELITY PCR buffer, 50 ng plasmid DNA, 2.5 U HOTSTAR™HIFIDELITY DNA polymerase.

Amplification is performed using e.g., the following cycling protocol:initial activation step at 95° C. for 5 min, followed by 25 cycles ofdenaturation at 95° C. for 45 s, annealing at 55° C. for 1 min,extension at 72° C. for 1 min and final extension at 72° C. for 10 min.PCR products will be purified using QIAQUICK™ PCR PURIFICATION KIT(QIAGEN®, Germany) according manufacturer's instructions and the DNAeluted using 20 μl nuclease-free water. The quality and purity of theDNA can be assessed by 1% agarose gel electrophoresis.

After the PCR, the genetic information is transcribed from DNA to mRNAin vitro using e.g., MEGASCRIPT® T7 Kit (LIFE TECHNOLOGIES®, Germany).The mRNA transcript then will be used to induce protein expression incells. At first, 23 μl NTP/cap analog mixture containing 7.5 mM ATP,1.875 mM GTP (both from MEGASCRIPT® T7 Kit), 7.5 mM Me-CTP, 7.5 mMPseudo-UTP (both from TRILINK BIOTECHNOLOGIES™, CA), and 2.5 mM3′-O-Me-m⁷G(5′)ppp(5′)G RNA cap structure analog (NEW ENGLAND BIOLABS®,Germany) will be prepared and mixed thoroughly.

The IVT reaction mixture of 40 μl then will be assembled by adding 40 URIBOLOCK™ RNase inhibitor (THERMO FISHER SCIENTIFIC), 1 μg PCR product,1× reaction buffer and 1× T7 RNA polymerase enzyme mix. The IVT reactionmixture will be incubated at 37° C. for 3 hr in a thermomixer. To removethe template DNA, 1 μl TURBO™ DNase (from MEGASCRIPT® T7 Kit) is addedto the IVT reaction mixture and incubated for 15 min at 37° C. Then, thereaction mixture is purified using RNEASY™ Mini Kit (QIAGEN) accordingto manufacturer's instructions. The modified mRNA will be eluted fromthe spin column membrane twice with 40 μl nuclease-free water.

The generated mRNA will be treated with Antarctic phosphatase (NEWENGLAND BIOLABS®) to remove 5′ triphosphates, which can be recognized byRIG-1, and lead to the immune activation. Furthermore, the phosphatasetreatment prevents the recircularization in a self-ligation reaction.For this purpose, 9 μl of 10× Antarctic phosphatase reaction buffer isadded to 79 μl of purified mRNA solution. Subsequently, 2 μl ofAntarctic phosphatase (5 U/μl) is added to the reaction mixture andincubated at 37° C. for 30 min.

The treated mRNA can be purified using e.g., RNeasy Mini Kit (QIAGEN)according to manufacturer's instructions. The modified mRNA will beeluted from the spin column membrane twice with 50 μl nuclease-freewater. The concentration will be measured using SCANDROPspectrophotometer (ANALYTIC JENA, Germany). The concentration of mRNAwill be adjusted to 100 ng/μl by adding nuclease-free water. The qualityand purity of synthesized modified mRNA will be determined by 1% agarosegel electrophoresis. The modified mRNA will be aliquoted and stored at−80° C. and used for transfections.

ADSCs will be cultivated in α-MEM media supplemented with 10% FBS (LIFETECH.), 2 mM L-glutamine (PAA LABORATORIES, Austria), and 1%penicillin/streptomycin (PAA LAB.). Cells will be kept at 37° C. with 5%CO₂ and media will be changed every 3 days. Cells will be passaged usingtrypsin/EDTA (0.04%/0.03%, PROMOCELL™, Germany). For performing oftransfection experiments, 1.5×10⁵ cells will be plated per well of24-well plate. The cells will be incubated overnight at 37° C. in a cellincubator. Next day, transfection experiments can be performed.

Transfection of ADSCs with different mRNA of the invention are performedwith LIPOFECTAMINE® 2000 (LIFE TECH.®). To determine the required amountof LIPOFECTAMINE® 2000 for forming of lipoplexes, different amounts ofLIPOFECTAMINE® 2000, of 1, 2, 4, 6 were used to transfect the cells. Fortransfection of one well of 24-well plate, 250 μl Opti-MEM I reducedserum media was prepared containing 2.5 μg of each mRNA of interest andrespective amount of LIPOFECTAMINE® 2000 according to the manufacturer'sinstruction.

The components are gently mixed by pipetting. The transfection mixturethen is incubated at room temperature for 20 min to generate lipoplexesfor transfection. Cells will be washed with 250 μl DPBS/well, thetransfection mixture pipetted into the well. After 4 hr incubation at37° C. and 5% CO₂, the transfection mixture is replaced by 1 ml completecell culture medium. Cells will be cultivated for 24 hr in the cellincubator and analyzed using flow cytometry.

To determine the required amount of mRNA for induction of proteinexpression, firstly different amounts of every eGFP-mRNA, 0, 0.5, 1,1.5, 2, 2.5 μg, are used to perform the transfection of cells. Fortransfection of one well of 24-well plate, 250 μl Opti-MEM I reducedserum media with respective amount of mRNA and 1 μl of LIPOFECTAMINE®2000 will be prepared.

The components are gently mixed and incubated for 20 min at roomtemperature. Cells will be washed with 500 μl DPBS/well and thetransfection mixture will be added. Cells will be incubated for 4 hr at37° C. and 5% CO₂. Afterwards, the transfection mixture will beaspirated and 1 ml complete cell culture medium will be added to thecells. Cells will be incubated for 24 hr in the incubator.

Using flow cytometry, the eGFP expression in the cells is verified.After determining the required amount of mRNA for induction of proteinexpression by eGFP, the same concentration is applied for the respectivemRNA according to the invention.

Immunohistochemistry

For further characterization of induced pacemaker cells,immunohistochemistry (IHC) staining for the major maker genes of cardiacpacemaker cell lineages including CX30.2 and HCN4 were performed 2 weeksafter the initiation of Doxycycline triggered induction.

IHC staining was performed for two major marker genes respective ofnon-contractile cardiomyocytes including CX30.2 and HCN4. Results of IHCstaining in cells sequentially transformed with the SHOX2>TBX5>HCN2triplet revealed the expression of CX30.2 and HCN4 in both spindle andspider cell populations (FIG. 10, 11, 12). HCN4 is a member ofhyperpolarization activated cyclic nucleotide-gated sodium channelsrequired for If, the specific pacemaker current. CX30.2 is responsiblefor the cell-cell junctions and formation of networks between respectivenon-contractile cardiomyocytes.

Similar immunophenotype were also, observed in different groups of ADSCstransfected with other combinations of pacemaker inducing factors.However more robust changes in morphological properties andimmunophenotype of transfected ADSCs towards the spontaneouslydepolarizing, non-contractile cardiomyocytes were observed in ADSCgroups transfected with TBX transcription factors (particularly TBX5) incomparison to the groups transfected with individual or doublecombinations of SHOX2 and HCN2. The most robust changes in morphologicalproperties and immunophenotype of transfected ADSCs toward thesinoatrial node's cells were observed by triple combinations of SHOX2,TBX5 and HCN2. It's also possible that TBX3 and TBX18 can be used inaddition to or in replacement of TBX5, and that HCN4 can be used inaddition to or in replacement of HCN2.

Expression Levels of Key Genes

To evaluate the effect of various combinations of cardiac pacemakerinducing factors on differentiation of ADSCs towards the different typesof cardiac conduction cell lineages including pacemaker and Purkinjecells, mRNA expression level of specific marker genes of both celllineages were analyzed.

To this end mRNA expression for a panel of downstream late stage markersof cardiac pace maker cells, including HCN1, HCN3, HCN4, SCN3B (UniProtQ9NY72), CX30.2 (properly known as GJC3, UniProt Q8NFK1) as well asPurkinje cells' specific marker genes including IRX3 (UniProt P78415),IRX5 (UniProt P78411), SEMA3B (UniProt Q6PI51), SCN10A (UniProt Q9Y5Y9),SHH (UniProt Q15465) were determined applying qPCR analysis on a mixedcell type population (e.g., cells were not first separated intopacemaker and Purkinje cells, although this experiment is planned).

Briefly total RNA was isolated using the QIAGEN's® RNEASY™ Kit and werereverse transcribed into cDNA using Superscript III (INVITROGEN®).Quantitative PCR were performed with the ABI Prism 7000 System DetectionSequence (SDS) and software (APPLIED BIOSYSTEMS®) using SYBR Green(APPLIED BIOSYSTEMS®) as the detector.

The mRNA expression level for a panel of specific marker genes ofcardiac pacemaker marker (Table 3 and FIG. 12) and Purkinje cells (Table2 and FIG. 13) were analyzed thereby. Based on the results of qPCRanalysis expression of marker genes of cardiac Purkinje cell can beobserved in all different experimental groups transfected with differentcombinations of pacemaker inducing factors. However differentcombinations of cardiac inducing factors play various roles onup-regulation of downstream cardiac pacemaker marker genes includingHCN1, HCN3, HCN4, SCN3B (UniProt Q9NY72), CX30.2 (GJC3, UniProt Q8NFK1).

For example the highest mRNA expression level of HCN3B, HCN3 and CX30.2were observed in ADSCs transfected with triple combination of SHOX2,TBX5 and HCN2, while mRNA expression of HCN1 is more correlated with theup-regulation of TBX18. According to the results of this study, mRNAexpression of HCN4 is highly correlated with the up-regulation of SHOX2.In addition moderate expression level of HCN4 was observed in ADSCstransfected with triple combinations of SHOX2, TBX5 and HCN2. Alltogether based on the results of qPCR, transfection of ADSCs with triplecombinations of SHOX2, TBX5 and HCN2 leads the most consistentup-regulation of different marker genes of cardiac conductive cells. Itcan be concluded that the most robust changes in gene expression patternof transfected ADSCs towards the spontaneously depolarizing,non-contractile cardiomyocytes were observed in ADSC groups transfectedwith TBX transcription factors (particularly TBX5) in comparison to thegroups transfected with individual or double combinations of SHOX2 andHCN2. The most robust and consistent changes in gene expression patternof transfected ADSCs toward the spontaneously depolarizing,non-contractile cardiomyocytes were observed by triple combinations ofSHOX2, TBX5 and HCN2.

Generally it can be concluded that triple combinations of SHOX2, TBX5and HCN2 can be applied effectively for generation of both cell types ofcardiac conductive system including Purkinje and Pacemaker cells.

TABLE 2 List of forward (F) and reverse (R)primer sequences for specific marker genes of cardiac Purkinje cellsPrimer's Nucleotide Gene name name sequence of primer Iroquois  IRX3 FGAGGGAAACGCTTATGGG homebox- (SEQ ID NO. 1) AGC 5 (IRX3) IRX3 RCGCCGTCTAAGTTCTCCA (SEQ ID NO. 2) AATC Iroquois IRX5 FTCAGCGACTCGGATTTTA homebox- (SEQ ID NO. 3) AGGA 5 (IRX5) IRX5 RGGAGGCGGCGAATGGATA (SEQ ID NO. 4) A Semaphorine  SEMA3B FACATTGGTACTGAGTGCA (SEMA3B) (SEQ ID NO. 5) TGAAC SEMA3B RGCCATCCTCTATCCTTCC (SEQ ID NO. 6) TGG Sodium channel SCN10A FTCCCTCGAAACTAACAAC voltage (SEQ ID NO. 7) TTCCG gated 10 SCN10ARTCTGCTCCCTATGCTTCT (SCN10A) (SEQ ID NO. 8) CTC Sonic Hedge SHH FCCAAGGCACATATCCACT hog (SHH) (SEQ ID NO. 9) GCT SHH R GTCTCGATCACGTAGAAG(SEQ ID NO. 10) ACCT

TABLE 3 List of forward (F) and reverse (R)primer sequences for specific marker genes of cardiac Pacemaker cellsNucleotide Gene name Primer's name sequence of primer HyperpolarizationHCN1 F CATGCCACCGCTTTAATC activated cyclic (SEQ ID NO. 11) CAGnucleotide ion HCN1 R ATTGTAGCCACCAGTTTC channel-1 (HCN1)(SEQ ID NO. 12) CGA Hyperpolarization HCN3 F AGCAGTGGAAATCGAGCAactivated cyclic (SEQ ID NO. 13) GG nucleotide ion HCN3 RGGTCCCAGTAAAACCGGA channel-3 (HCN3) (SEQ ID NO. 14) AGTHyperpolarization HCN4 F GAACAGGAGAGGGTCAAG activated cyclic(SEQ ID NO. 15) TCG nucleotide ion HCN4 R CATTGAAGACAATCCAGGchannel-3 (HCN3) (SEQ ID NO. 16) GTGT Sodium Channel, SCN3B FGCCTTCAATAGATTGTTT Voltage gated 3b (SEQ ID NO. 17) CCCCT (SCN3B)SCN3B R CTCGGGCCTGTAGAACCA (SEQ ID NO. 18) T Connexin 30.2 CX30.2 FTGGAGTCAGCGGTTTCTG (CX30.2) (SEQ ID NO. 19) TC CX-30.2 RTTGTGTCTTCTGGTGCTC (SEQ ID NO. 20) TCT

Patch Clamp Assays

To further verify the functionality of genetically programmed pacemakercells their electrophysiological properties we performed single-cellpatch clamp experiments to measure the currents generated by the cells(White, 2005).

Whole cell voltage-clamp experiments were carried out using the standardpatch-clamp method. Recording electrodes were made from 1.5-mmthin-walled borosilicate glass (no. 7052, GARNER GLASS™, CA) using aFlaming-Brown microelectrode puller (P-97, SUTTER INSTRUMENTS™, CA) andheat polished before use. Each of the pipettes have a tip resistance of2-5 MS2 when filled with internal solution. Recordings were performedusing an Axoclamp 2B patch-clamp amplifier (AXON INSTRUMENTS™; CA). Datawere filtered at 2 kHz, and data acquired using Clampex 8 software (AXONINSTRUMENTS™).

Patch pipettes were pulled from borosilicate glass and heat polished.They had a resistance of 2-5 M≠ when filled with intercellular solution.

For current-clamp recordings, the intercellular solution was containing10 mM NaCl, 130 mM potassium aspartate, 0.04 mM CaCl₂. 3 mM Mg-ATP, 10mM HEPES. pH was adjusted to 7.2 with KOH. The extracellular (bath)solution contained 140 mM NaCl, 5.4 mM KCl, 1.8 mM CaCl₂, 1 mM MgCl₂, 10mM glucose, and 5 mM HEPES at pH 7.4.

Funny Current (If) density was measured with voltage steps from −100 mVto −40 mV for 500 mS with 10 mV increments from a holding potential of40 mV. Because an important characteristic of cardiac a pacemaker cellis the expression of an inward funny current (If). According to theresults of this study, both populations of small spindle cells as wellas large spider shape cells demonstrated a robust If current typicalcurrent of HCN channel subtypes (FIG. 15, 16, 17).

The present invention is exemplified with respect to lentiviral vectors.However, this is exemplary only, and the invention can be broadlyapplied to include any means for activating the requisite genes in stemcells, such as ADSC. The following examples are intended to beillustrative only, and not unduly limit the scope of the appendedclaims.

The following references are incorporated by reference in their entiretyfor all purposes.

-   Arnolds, D. E., et al., TBX5 drives SSN5A expression to regulate    cardiac conduction system function. J Clin Invest, 2012. 122(7): p.    2509-18.-   Avci-Adali, M., et al., Optimized conditions for successful    transfection of human endothelial cells with in vitro synthesized    and modified mRNA for induction of protein expression. J Biol    Eng, 2014. 8(1): p. 8.-   Bai, X., et al., Tracking long-term survival of intramyocardially    delivered human adipose tissue-derived stem cells using    bioluminescence imaging. Mol Imaging Biol, 2011. 13(4): p. 633-45.-   Bakker, M. L., et al., T-box transcription factor TBX3 reprogrammes    mature cardiac myocytes into pacemaker-like cells. Cardiovasc    Res, 2012. 94(3): p. 439-49.-   Cho, H. C. and E. Marban, Biological therapies for cardiac    arrhythmias: can genes and cells replace drugs and devices? Circ    Res, 2010. 106(4): p. 674-85.-   Diego S. D'Astolfo, D. S. et al., Efficient Intracellular Delivery    of Native Proteins, CELL 2015. 161(3): 674-690.-   DiFrancesco, D., et al., Properties of the hyperpolarizing-activated    current (if) in cells isolated from the rabbit sino-atrial node. J    Physiol, 1986. 377: p. 61-88.-   Hashem, S. I., et al., SHOX2 regulates the pacemaker gene program in    embryoid bodies. Stem Cells Dev, 2013. 22(21): p. 2915-26.-   Hatcher, C. J. and C. T. Basson, Specification of the cardiac    conduction system by transcription factors. Circ Res, 2009.    105(7): p. 620-30.-   Hoogaars, W. M., et al., TBX3 controls the sinoatrial node gene    program and imposes pacemaker function on the atria. Genes    Dev, 2007. 21(9): p. 1098-112.-   Hu, Y. F., et al., Biological pacemaker created by minimally    invasive somatic reprogramming in pigs with complete heart block.    Sci Transl Med, 2014. 6(245): p. 245ra94.-   Islas, J. F., et al., Transcription factors ETS2 and MESP1    transdifferentiate human dermal fibroblasts into cardiac    progenitors. P.N.A.S. USA, 2012. 109(32): p. 13016-21.-   Jung, J. J., et al., Programming and isolation of highly pure    physiologically and pharmacologically functional sinus-nodal bodies    from pluripotent stem cells. Stem Cell Reports, 2014. 2(5): p.    592-605.-   Kapoor, N., et al., Direct conversion of quiescent cardiomyocytes to    pacemaker cells by expression of TBX18. Nat Biotechnol, 2013.    31(1): p. 54-62.-   Stankovicova, T., et al., Isolation and morphology of single    Purkinje cells from the porcine heart. Gen Physiol Biophys, 2003.    22(3): p. 329-40.-   White, S. M. and W. C. Claycomb, Embryonic stem cells form an    organized, functional cardiac conduction system in vitro. Am J    Physiol Heart Circ Physiol, 2005. 288(2): p. H670-9.

All UniProt cites herein are incorporated by reference herein, includingthe sequences linked thereto, in their entirety for all purposes.

1. A method of treating an arrhythmia, comprising a) obtaining adultstem cells from a patient with an arrhythmic heart, wherein the adultstem cell is obtained from bone narrow, umbilical cord tissue, umbilicalcord blood, placenta, adipose tissue, root of hair, or omental fatcontaining blood vessels; b) inducing lineage commitment of said adultregenerative cells towards Purkinje and pacemaker cardiomyocyte cellsthrough sequential epigenetic re-programming, and c) introducing saidPurkinje cells or said pacemaker cells, or both, into said arrhythmicheart.
 2. The method of claim 1, wherein the adult stem cells are adultadipose tissue-derived stem cells.
 3. The method of claim 1, wherein theadult stem cells are uncultured prior to the inducing step b).
 4. Themethod of claim 1, wherein the sequential epigenetic re-programmingcomprises sequentially expressing SHOX2>TBX5>HCN2 in the adultregenerative cells.
 5. The method of claim 1, wherein both saidpacemaker cells and said Purkinje cells are used together toreconstitute a damaged sinus node of said patient.
 6. A compositioncomprising an induced sinoatrial body in a pharmaceutically acceptablebuffer and/or cellular support medium, wherein the sinoatrial body ismade by the following method: a) sequentially expressing SHOX2>TBX5>HCN2in a population of adult adipose tissue-derived stem cells in order toinduce specific differentiation of said cells, and b) growing said cellsuntil cardiac pacemaker cells and Purkinje cells form.
 7. Thecomposition of claim 6, wherein said adult adipose tissue-derived stemcells are autologous.
 8. The method of claim 6, wherein step a)comprises inducing the sequential transfection of DNA or mRNA encodingSHOX2>TBX5>HCN2 into said cells.
 9. The method of claim 6, wherein stepa) comprises inducing the sequential expression ofSHOX2>TBX3>TBX5>TBX18>HCN2.